Pennsylvania billing is shaped by two forces: a Medicaid program divided into regional zones, and two integrated payer-provider systems, UPMC and Highmark, that dominate both insurance and care delivery. A practice that doesn’t know its zone’s plans, or that bills an integrated system like any other payer, leaves revenue on the table.
MedPlus RCM provides medical billing, coding, credentialing, and denial management for Pennsylvania practices of every specialty, built around the state’s actual payers and programs.
Pennsylvania’s payer landscape
Pennsylvania Medicaid is delivered through HealthChoices, a mandatory managed care program divided into geographic zones. Each zone has its own set of managed care organizations, including UPMC for You, Highmark Wholecare, Keystone First, AmeriHealth Caritas Pennsylvania, Geisinger Health Plan, Health Partners Plans, Aetna Better Health, and UnitedHealthcare Community Plan. Not every plan operates in every county, and each has its own authorization and referral logic.
Commercial coverage is dominated by UPMC Health Plan, Highmark, and Independence Blue Cross, with Capital BlueCross, Aetna, and Cigna also carrying significant volume. Because UPMC and Highmark are integrated payer-provider systems, their billing and referral rules reflect both sides of that relationship, a detail a generalist billing process often misses.
What MedPlus RCM handles for Pennsylvania practices
- End-to-end medical billing. Charge entry, claim scrubbing, submission, payment posting, and patient billing, the full cycle.
- Medical coding. Certified coders assign current ICD-10, CPT, and HCPCS codes matched to your documentation and specialty.
- Provider credentialing and enrollment. End-to-end enrollment with HealthChoices plans, commercial payers, and Medicare, plus re-credentialing maintenance.
- Denial management and recovery. Every denial investigated to root cause, corrected, and appealed with documentation.
- A/R recovery. Aged and outstanding balances audited and pursued, including balances already written off where the appeal window is still open.
- Financial reporting. Clean claim rates, collections, denial patterns, and A/R aging visible by payer and provider.
We serve practices statewide, Philadelphia, Pittsburgh, Allentown, Harrisburg, Erie, and Scranton, across specialties including primary care, mental and behavioral health, cardiology, orthopedics, dermatology, and physical therapy.
Results Pennsylvania practices can check
MedPlus RCM maintains a 99% clean claim rate and keeps client accounts receivable under 30 days. Pricing is a performance-based percentage of successfully collected revenue: if you don’t get paid, we don’t get paid. We are 100% HIPAA compliant, and onboarding takes 2 to 4 weeks depending on practice size, with no disruption to your daily cash flow.
Frequently asked questions
What is HealthChoices?
HealthChoices is Pennsylvania’s mandatory Medicaid managed care program. Members enroll with a managed care organization in their geographic zone, such as UPMC for You, Keystone First, or Highmark Wholecare, and practices bill that plan.
Do you work with HealthChoices plans?
Yes. We bill HealthChoices plans including UPMC for You, Highmark Wholecare, Keystone First, AmeriHealth Caritas, Geisinger, Health Partners Plans, Aetna Better Health, and UnitedHealthcare Community Plan, as well as commercial and Medicare plans.
How long does it take to switch our billing to MedPlus RCM?
Onboarding takes between 2 and 4 weeks depending on practice size, including data migration and payer clearinghouse setup.
What does MedPlus RCM charge?
A performance-based percentage of successfully collected revenue. If you don’t get paid, we don’t get paid.
Get a free financial audit
Find out where your Pennsylvania practice is losing revenue. Request a free financial audit and our specialists will review your claims, denials, and A/R.
